Application for Instrastate Motor Carrier License

___
OFFICIAL USE ONLY
USDOT NO.
________________
Amount Received ____________________________________
PIN
________________
Processed By ____________ Date Processed ______________
SUB NO.
________________
TDF 1(02-11)
APPLICATION FOR INTRASTATE MOTOR CARRIER LICENSE
1. USDOT Number______________________________ FEIN/SSN___________________________________________
Applicant ___________________________________________________________________________________________________________
Doing business as (trade name if any) ____________________________________________________________________________________
2. Addresses and Contact Information
Mailing Address 1
c/o ____________________________________________________
P.O. or Street ____________________________________________
City, State, Zip ___________________________________________
Telephone No. (_____)___________ Fax No. (_____)___________
Email __________________________________________________
Mailing Address 2
c/o _____________________________________________________
P.O. or Street ____________________________________________
City, State, Zip ___________________________________________
Telephone No. (_____)___________ Fax No. (_____)___________
Email __________________________________________________
Carrier’s Physical Address or Location
Street __________________________________________________
City, State, Zip ___________________________________________
Carrier’s Contact Person ___________________________________
Telephone # _(________)__________________________________
Domicile County _________________________________________
3. Type of Applicant ❏ SOLE PROPRIETORSHIP ❏ CORPORATION ❏ PARTNERSHIP ❏ OTHER
4. Principal Place of Business State (PPB) _____________________________________________________________________________________
If Principal Place of Business State is Oklahoma, is Applicant properly registered with the Oklahoma Secretary of State? ❏ YES ❏ NO
If PPB State is not Oklahoma, provide:
Proposed/Actual Major Oklahoma Terminal or Home Office
Street __________________________________________________
City, State, Zip ___________________________________________
Oklahoma Process Agent
Name _________________________________________________
Street __________________________________________________
City, State, Zip ___________________________________________
5. Type of Proposed Operations (Check all that apply.)
For Hire Carrier
PROPERTY (Not Deleterious, Hazardous or Passengers)
❏Restricted ❏Unrestricted ❏10,001 GVWR or under
DELETERIOUS
❏Deleterious Substances (also requires TDF 14)
HAZARDOUS MATERIALS (may also require Haz Waste application)
❏Hazardous Materials $1 million ❏Hazardous Materials $5 million
PASSENGERS Vehicle Seating Capacity
❏Taxicab Service ❏15 passengers or less ❏16 passengers or more
Private Carrier
PROPERTY (Not Deleterious, Hazardous or Passengers)
❏Property
DELETERIOUS
❏Deleterious Substances (also requires TDF 14)
HAZARDOUS MATERIALS (may also require Haz Waste application)
❏Hazardous Materials $1 million ❏Hazardous Materials $5 million
6. Does the applicant conduct interstate operations (across state lines)? ❏YES ❏NO Is the applicant registered in the UCR program? ❏YES ❏NO
7. Does the application intend to operate vehicles with a GVWR, GCWR, loaded weight or registered weight over 26,000 pounds? ❏YES or ❏NO
8. Quantity of Identification Devices. Stamps ______________________ 9. Rule Book Serial No. ____________________________
The Applicant hereby declares that it has knowledge of and understands the rules of the Oklahoma Corporation Commission governing transportation by motor carriers and private carriers; that said rules and regulations will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for; and that under penalty of perjury, all statements and representations appearing in the foregoing application and all addendums are based upon my knowledge of the matters referred to and are true and correct.
Applicant’s Signature _______________________________________________________________________________________________________
Applicant’s Title __________________________________________________________________________________________________________
Attorney’s Signature (if any) _________________________________________________________________________________________________OKLAHOMA CORPORATION COMMISSION
TRANSPORTATION DIVISION
P.O. BOX 52000 OKLAHOMA CITY, OK 73152-2000
JIM THORPE OFFICE BUILDING 2101 N. LINCOLN BLVD. ROOM 312 73105-4904
TELEPHONE (405) 521-2251 FAX NO. (405) 521-2916
INTERNET ADDRESS http://www.occeweb.com
OAC 165:30-3-1; OAC 165:30-15-4
Please keep a copy of this completed application in your office. In the event we have any questions about your application and contact you, it will be helpful as a reference tool. Please make your check or money order payable to the Oklahoma Corporation Commission. All fees may be remitted in one check / money order. The application must be signed. ORIGINAL APPLICATION MUST BE FILED WITH ALL ATTACHMENTS. Application must be submitted with $100 filing fee plus additional fees as shown below. Please print or type application.
1. Applicant must be a legal entity (individual, corporation, partnership, etc.). A DBA (doing business as) may be indicated, but application cannot be filed in a trade name only. If a partnership, the Applicant must reflect the names of each of the partners. The Applicant’s USDOT number must be listed on this application. If the USDOT number is not yet issued, a copy of the completed MCS-150 mailed to FMCSA must be attached. An Applicant operating solely intrastate must apply for an intrastate USDOT number, issued by this Commission, using a TDF 19 application. The Applicant’s FEIN or individual’s SSN must be listed.
2. Mailing Address 1 is the location to which all correspondence is to be mailed. Permit service, attorney’s office, carrier’s address, or other location may be listed. If the address listed in Mailing Address 1 is NOT the carrier’s address, the carrier’s address MUST be listed in the Mailing Address 2 column. Carrier’s Physical Address or Location is the carrier’s actual physical location. If you have an out-of-state address, do not provide Domicile County.
3. For Type of Applicant, choose your organization type.
4. If your organization is other than a Sole Proprietorship and your principal place of business is Oklahoma, you must be properly filed with the Oklahoma Secretary of State’s office (405) 521-3911 and a copy of the certificate of incorporation or similar paper must be submitted with this application. If your organization is other than a Sole Proprietorship and your principal place of business is other than Oklahoma, you must provide the address of your proposed or actual major Oklahoma terminal or home office along with either name and address of your Oklahoma Process Agent or a copy of your BOC-3 Process Agent Listing.
5. In the Type of Proposed Operations section, please check all that apply. Minimum liability insurance limits are based upon your type of operations. See “Liability Insurance” below. If more than one category is marked, the highest liability insurance limit is required.
6. If you operate a commercial motor vehicle transporting interstate (across state lines) shipments, you are subject to the Unified Carrier Registration Program. A “commercial motor vehicle” is defined as a self-propelled vehicle used on the highway in interstate commerce principally to transport passengers or cargo, if the vehicle: (a) has a gross vehicle weight rating or gross vehicle weight of 10,001pounds or more; (b) is designed to transport 10 or more passengers (including the driver); or (c) is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U.S.C. Section 5103 and transported in a quantity requiring placarding under regulations prescribed by the U.S. Secretary of Transportation.
7. If you intend to operate vehicles with a gross vehicle weight rating (GVWR) as specified by the manufacturer, gross combination weight rating (GCWR), loaded weight or registered weight thereof over 26,000 pounds; placarded amounts of hazardous materials or passengers 15 or more, you will be subject to federal safety regulations and a safety review, even if your vehicles are solely intrastate.
8. Please list the number of identification devices (stamps) you wish to request. One device is required for each vehicle. Please remit $7.00 for each identification device. Additional identification devices may be ordered throughout the year using application TDF 16 or a written letter.
9. If you have the rule book in your possession, you must list its serial number. Every intrastate motor carrier must possess a current OCC Chapter 30 rule book. Rule books are available at a cost of $10 per rule book or you may download the document from our website. If you purchase a rule book, notices of rule changes will be provided to you. If your rule book serial number is 39600 or higher, you already possess the most current rule book.
Liability Insurance - An insurance filing (typically a Form E) must be filed with this office as proof of liability insurance. The name, address and liability limits must EXACTLY match the information shown on the front of this application. You may need to contact your insurance agent to inform the insurance company to provide the insurance filing to this office. (Agents do not typically provide the required filing.) Liability insurance requirements are combined single limits as follows:
• Property (for hire)
o Unrestricted - $750,000
o Restricted (Sand, rock, gravel, asphaltic mixtures and similar road building materials; Unprocessed forestry products; Unprocessed agricultural commodities; Ordinary livestock) - $350,000
o Under 10,000 pounds GVWR - $300,000
• Property (private carrier) - $350,000
• Deleterious substances (non hazardous) - $750,000:
• Taxicab service utilizing vehicles having a seating capacity of 6 passengers or less not operated on a regular route or between specified points - $100,000; 15 passengers or less, other than taxicab service-$1,000,000; 16 or more passengers-$5,000,000. Seating capacity includes the driver.
• Hazardous materials as defined in and as required by OAC 165:30-3-11 and 49 CFR Part 387.TDF 1
ATTACHMENT "A"
PART 1 LEGAL ENTITY INFORMATION (other than an individual/sole proprietorship)
Date of Incorporation ________________________ State of Incorporation________________________________
Attach copy of document/cover page filed with the Secretary of State or Partnership agreement.
Name of Officer/Partner
Title of Officer/Partner
Address of Officer/Partner
PART 2 OPERATIONAL INFORMATION
Mark the type of commodities anticipated to be most generally transported. Check all that apply.
❏Courier Service
❏Livestock, ordinary
❏Sand, rock, gravel
❏Unprocessed agricultural or forestry products
❏Manure
❏Automobiles/motor vehicles
❏Beer and alcoholic beverages
❏Boats
❏Bio-medical waste
❏Cement and fly ash
❏Coal/coke
❏Deleterious substances
❏Driveaway/towaway
❏Electric transmission & communications equipment
❏Feed and feed ingredients
❏Garbage, refuse, trash
❏Groceries, processed food, frozen food
❏Household goods, new
❏Household goods, used
❏Houses
❏Lumber, building and construction materials
❏Hazardous Materials
(Complete Part 4 Hazardous Materials.)
❏Mobile homes, portable buildings
❏Oilfield/heavy equipment and articles/large objects
❏Paper and paper products
❏Passengers
Specify largest vehicle seating capacity,
including driver ___________________
❏Retail commodities
❏Other
Describe_______________________PART 3 HAZARDOUS MATERIALS
• If you left all Hazardous Materials options blank in question 5 of the application itself, you may skip this section.
• If you answer “No” to questions 2 and 3 of the Safety Summary Report, you may skip this section. (The Safety Summary Report is Part 5 of this Attachment A.)
Mark the Division/type of hazardous materials anticipated to be most generally transported - (Check all that apply.)
❏Div 1.1 Explosives (with mass explosion hazard)
❏Div 1.2 Explosives (with projection hazard)
❏Div 1.3 Explosives (with predominantly fire hazard)
❏Div 1.4 Explosives (with no significant blast hazard)
❏Div 1.5 Very insensitive explosives; blasting agents
❏Div 1.6 Extremely insensitive detonating substances
❏Div 2.1 Flammable gas
❏Div 2.1 LPG (Liquefied Petroleum Gas)
❏Div 2.1 Methane Gas
❏Div 2.2 Non-flammable compressed gas
❏Div 2.2 A (Anhydrous Ammonia)
❏Div 2.3 A (Poison Gas which is Poison inhalation Hazard (PIH) Zone A)
❏Div 2.3 B (Poison Gas which is PIH Zone B)
❏Div 2.3 C (Poison Gas which is PIH Zone C)
❏Div 2.3 D (Poison Gas which is PIH Zone D)
❏Class 3 Flammable and combustible liquid
❏Class 3 A (Flammable liquid which is a PIH Zone A)
❏Class 3 B (Flammable liquid which is a PIH Zone B)
❏Combustible Liquid (Refer to 49 CFR 173.120 (b)
❏Div 4.1 Flammable solid
❏Div 4.2 Spontaneously combustible material
❏ Div 5.1 Oxidizer
❏ Div 5.2 Organic peroxide
❏ Div 6.1 A (Poison Liquid which is a PIH Zone A)
❏ Div 6.1 B (Poison Liquid which is a PIH Zone B)
❏ Div 6.1 Poison (Poisonous liquid with no inhalation hazard)
❏ Div 6.1 Solid (meets the definition of a poisonous solid)
❏ Div 6.2 Infectious substance (Etiologic agent)
❏ Class 7 Radioactive material
❏ HRCQ (Highway Route Controlled Quantity of Radioactive material)
❏ Class 8 Corrosive material
❏ Class 8 A (Corrosive liquid which is a PIH Zone A)
❏ Class 8 B (Corrosive liquid which is a PIH Zone B)
❏ Class 9 Miscellaneous hazardous material
❏ Elevated Temperature Material (Meets definition in 49 CFR171.8 for an elevated temperature material)
❏ Infectious Waste (Meets definition in 49CFR 171.8 for an infectious waste
❏ Marine Pollutants (Meets definition in 49 CFR 171.8 for a marine pollutant)
❏ Hazardous Sub (RQ) (Meets definition in 49 CFR 171.8 of a reportable quantity of a hazardous substance)
❏ Hazardous Waste (Meets definition in 49 CFR 171.8 of a hazardous waste)
❏ ORM (Meets definition in 49 CFR 171.8 of Other Regulated material)
Note: Information on Poison Inhalation Hazards is found in column (7) of the hazardous materials table (49 CFR 172.101)
INTRA / INTER HAZARDOUS MATERIALS CARRIERS/SHIPPERS – IS YOUR COMPANY REGISTERED WITH RSPA?
Please refer to 49 CFR, Part 107.601 regarding the applicability of registration of persons who offer or transport hazardous materials. If your company meets the criteria listed, call Research and Special Programs Administration (RSPA) of the Federal Highway Administration at (202) 366-4109 for the appropriate application forms or download from http://www.rspa.dot.gov .PART 4 EQUIPMENT LISTING / TERMINAL & DOCK FACILITIES
List the following information for all vehicles (power units) and equipment (trailers) to be operated under the license. Attach additional pages if necessary. A computer printout listing the power units/equipment/trailers information required may be submitted.
POWER UNITS
Vehicle I.D. Number (VIN)
Year
Make
Type*
Describe Type
GVWR or Capacity
Tag No
State
Owned(O) or Leased(L)
* Type of power unit such as Straight Truck (ST), Truck Tractor (TT), Pickup (PU), Limousine, Taxi, Car, etc. If “Other”, please describe in the column called “Describe Type.”
EQUIPMENT / TRAILERS
* Type of Equipment or Trailers such as Gooseneck, Flatbed, Box, Belly Dump, Pole Trailer, etc.
DESCRIPTION OF TERMINAL or DOCK If your company does not maintain a terminal, dock or motor pool facility, please list the physical address (physical location) where vehicles are parked when not in use. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PART 5 SAFETY SUMMARY REPORT
1. Does applicant intend to operate vehicles with a GVWR or GCWR over 26,000 pounds? ❏YES or ❏NO
2. Does applicant intend to transport hazardous materials requiring placarding? ❏YES or ❏NO
3. Does applicant intend to transport hazardous waste requiring a uniform manifest? ❏YES or ❏NO
4. Are your company’s CDL drivers employees and/or owner/operators?
❏Employees ❏Owner/Operators ❏Do not have CDL drivers
5. Provide applicant's USDOT safety rating:
❏No safety rating ❏Unsatisfactory ❏Conditional ❏Satisfactory ❏ Do not know
APPLICANT CERTIFICATION - SAFETY
The applicant certifies the federal motor carrier safety regulations, as adopted by the State of Oklahoma, will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for.
Initials
APPLICANT CERTIFICATION - SIZE AND WEIGHT SUMMARY REPORT
The applicant certifies the size and weight law as set forth by the State of Oklahoma, will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for.
Initials
Vehicle I.D. Number (VIN)
Year
Make
Type*
GVWR or Capacity
Tag No
State
Owned(O) or Leased(L)

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___
OFFICIAL USE ONLY
USDOT NO.
________________
Amount Received ____________________________________
PIN
________________
Processed By ____________ Date Processed ______________
SUB NO.
________________
TDF 1(02-11)
APPLICATION FOR INTRASTATE MOTOR CARRIER LICENSE
1. USDOT Number______________________________ FEIN/SSN___________________________________________
Applicant ___________________________________________________________________________________________________________
Doing business as (trade name if any) ____________________________________________________________________________________
2. Addresses and Contact Information
Mailing Address 1
c/o ____________________________________________________
P.O. or Street ____________________________________________
City, State, Zip ___________________________________________
Telephone No. (_____)___________ Fax No. (_____)___________
Email __________________________________________________
Mailing Address 2
c/o _____________________________________________________
P.O. or Street ____________________________________________
City, State, Zip ___________________________________________
Telephone No. (_____)___________ Fax No. (_____)___________
Email __________________________________________________
Carrier’s Physical Address or Location
Street __________________________________________________
City, State, Zip ___________________________________________
Carrier’s Contact Person ___________________________________
Telephone # _(________)__________________________________
Domicile County _________________________________________
3. Type of Applicant ❏ SOLE PROPRIETORSHIP ❏ CORPORATION ❏ PARTNERSHIP ❏ OTHER
4. Principal Place of Business State (PPB) _____________________________________________________________________________________
If Principal Place of Business State is Oklahoma, is Applicant properly registered with the Oklahoma Secretary of State? ❏ YES ❏ NO
If PPB State is not Oklahoma, provide:
Proposed/Actual Major Oklahoma Terminal or Home Office
Street __________________________________________________
City, State, Zip ___________________________________________
Oklahoma Process Agent
Name _________________________________________________
Street __________________________________________________
City, State, Zip ___________________________________________
5. Type of Proposed Operations (Check all that apply.)
For Hire Carrier
PROPERTY (Not Deleterious, Hazardous or Passengers)
❏Restricted ❏Unrestricted ❏10,001 GVWR or under
DELETERIOUS
❏Deleterious Substances (also requires TDF 14)
HAZARDOUS MATERIALS (may also require Haz Waste application)
❏Hazardous Materials $1 million ❏Hazardous Materials $5 million
PASSENGERS Vehicle Seating Capacity
❏Taxicab Service ❏15 passengers or less ❏16 passengers or more
Private Carrier
PROPERTY (Not Deleterious, Hazardous or Passengers)
❏Property
DELETERIOUS
❏Deleterious Substances (also requires TDF 14)
HAZARDOUS MATERIALS (may also require Haz Waste application)
❏Hazardous Materials $1 million ❏Hazardous Materials $5 million
6. Does the applicant conduct interstate operations (across state lines)? ❏YES ❏NO Is the applicant registered in the UCR program? ❏YES ❏NO
7. Does the application intend to operate vehicles with a GVWR, GCWR, loaded weight or registered weight over 26,000 pounds? ❏YES or ❏NO
8. Quantity of Identification Devices. Stamps ______________________ 9. Rule Book Serial No. ____________________________
The Applicant hereby declares that it has knowledge of and understands the rules of the Oklahoma Corporation Commission governing transportation by motor carriers and private carriers; that said rules and regulations will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for; and that under penalty of perjury, all statements and representations appearing in the foregoing application and all addendums are based upon my knowledge of the matters referred to and are true and correct.
Applicant’s Signature _______________________________________________________________________________________________________
Applicant’s Title __________________________________________________________________________________________________________
Attorney’s Signature (if any) _________________________________________________________________________________________________OKLAHOMA CORPORATION COMMISSION
TRANSPORTATION DIVISION
P.O. BOX 52000 OKLAHOMA CITY, OK 73152-2000
JIM THORPE OFFICE BUILDING 2101 N. LINCOLN BLVD. ROOM 312 73105-4904
TELEPHONE (405) 521-2251 FAX NO. (405) 521-2916
INTERNET ADDRESS http://www.occeweb.com
OAC 165:30-3-1; OAC 165:30-15-4
Please keep a copy of this completed application in your office. In the event we have any questions about your application and contact you, it will be helpful as a reference tool. Please make your check or money order payable to the Oklahoma Corporation Commission. All fees may be remitted in one check / money order. The application must be signed. ORIGINAL APPLICATION MUST BE FILED WITH ALL ATTACHMENTS. Application must be submitted with $100 filing fee plus additional fees as shown below. Please print or type application.
1. Applicant must be a legal entity (individual, corporation, partnership, etc.). A DBA (doing business as) may be indicated, but application cannot be filed in a trade name only. If a partnership, the Applicant must reflect the names of each of the partners. The Applicant’s USDOT number must be listed on this application. If the USDOT number is not yet issued, a copy of the completed MCS-150 mailed to FMCSA must be attached. An Applicant operating solely intrastate must apply for an intrastate USDOT number, issued by this Commission, using a TDF 19 application. The Applicant’s FEIN or individual’s SSN must be listed.
2. Mailing Address 1 is the location to which all correspondence is to be mailed. Permit service, attorney’s office, carrier’s address, or other location may be listed. If the address listed in Mailing Address 1 is NOT the carrier’s address, the carrier’s address MUST be listed in the Mailing Address 2 column. Carrier’s Physical Address or Location is the carrier’s actual physical location. If you have an out-of-state address, do not provide Domicile County.
3. For Type of Applicant, choose your organization type.
4. If your organization is other than a Sole Proprietorship and your principal place of business is Oklahoma, you must be properly filed with the Oklahoma Secretary of State’s office (405) 521-3911 and a copy of the certificate of incorporation or similar paper must be submitted with this application. If your organization is other than a Sole Proprietorship and your principal place of business is other than Oklahoma, you must provide the address of your proposed or actual major Oklahoma terminal or home office along with either name and address of your Oklahoma Process Agent or a copy of your BOC-3 Process Agent Listing.
5. In the Type of Proposed Operations section, please check all that apply. Minimum liability insurance limits are based upon your type of operations. See “Liability Insurance” below. If more than one category is marked, the highest liability insurance limit is required.
6. If you operate a commercial motor vehicle transporting interstate (across state lines) shipments, you are subject to the Unified Carrier Registration Program. A “commercial motor vehicle” is defined as a self-propelled vehicle used on the highway in interstate commerce principally to transport passengers or cargo, if the vehicle: (a) has a gross vehicle weight rating or gross vehicle weight of 10,001pounds or more; (b) is designed to transport 10 or more passengers (including the driver); or (c) is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U.S.C. Section 5103 and transported in a quantity requiring placarding under regulations prescribed by the U.S. Secretary of Transportation.
7. If you intend to operate vehicles with a gross vehicle weight rating (GVWR) as specified by the manufacturer, gross combination weight rating (GCWR), loaded weight or registered weight thereof over 26,000 pounds; placarded amounts of hazardous materials or passengers 15 or more, you will be subject to federal safety regulations and a safety review, even if your vehicles are solely intrastate.
8. Please list the number of identification devices (stamps) you wish to request. One device is required for each vehicle. Please remit $7.00 for each identification device. Additional identification devices may be ordered throughout the year using application TDF 16 or a written letter.
9. If you have the rule book in your possession, you must list its serial number. Every intrastate motor carrier must possess a current OCC Chapter 30 rule book. Rule books are available at a cost of $10 per rule book or you may download the document from our website. If you purchase a rule book, notices of rule changes will be provided to you. If your rule book serial number is 39600 or higher, you already possess the most current rule book.
Liability Insurance - An insurance filing (typically a Form E) must be filed with this office as proof of liability insurance. The name, address and liability limits must EXACTLY match the information shown on the front of this application. You may need to contact your insurance agent to inform the insurance company to provide the insurance filing to this office. (Agents do not typically provide the required filing.) Liability insurance requirements are combined single limits as follows:
• Property (for hire)
o Unrestricted - $750,000
o Restricted (Sand, rock, gravel, asphaltic mixtures and similar road building materials; Unprocessed forestry products; Unprocessed agricultural commodities; Ordinary livestock) - $350,000
o Under 10,000 pounds GVWR - $300,000
• Property (private carrier) - $350,000
• Deleterious substances (non hazardous) - $750,000:
• Taxicab service utilizing vehicles having a seating capacity of 6 passengers or less not operated on a regular route or between specified points - $100,000; 15 passengers or less, other than taxicab service-$1,000,000; 16 or more passengers-$5,000,000. Seating capacity includes the driver.
• Hazardous materials as defined in and as required by OAC 165:30-3-11 and 49 CFR Part 387.TDF 1
ATTACHMENT "A"
PART 1 LEGAL ENTITY INFORMATION (other than an individual/sole proprietorship)
Date of Incorporation ________________________ State of Incorporation________________________________
Attach copy of document/cover page filed with the Secretary of State or Partnership agreement.
Name of Officer/Partner
Title of Officer/Partner
Address of Officer/Partner
PART 2 OPERATIONAL INFORMATION
Mark the type of commodities anticipated to be most generally transported. Check all that apply.
❏Courier Service
❏Livestock, ordinary
❏Sand, rock, gravel
❏Unprocessed agricultural or forestry products
❏Manure
❏Automobiles/motor vehicles
❏Beer and alcoholic beverages
❏Boats
❏Bio-medical waste
❏Cement and fly ash
❏Coal/coke
❏Deleterious substances
❏Driveaway/towaway
❏Electric transmission & communications equipment
❏Feed and feed ingredients
❏Garbage, refuse, trash
❏Groceries, processed food, frozen food
❏Household goods, new
❏Household goods, used
❏Houses
❏Lumber, building and construction materials
❏Hazardous Materials
(Complete Part 4 Hazardous Materials.)
❏Mobile homes, portable buildings
❏Oilfield/heavy equipment and articles/large objects
❏Paper and paper products
❏Passengers
Specify largest vehicle seating capacity,
including driver ___________________
❏Retail commodities
❏Other
Describe_______________________PART 3 HAZARDOUS MATERIALS
• If you left all Hazardous Materials options blank in question 5 of the application itself, you may skip this section.
• If you answer “No” to questions 2 and 3 of the Safety Summary Report, you may skip this section. (The Safety Summary Report is Part 5 of this Attachment A.)
Mark the Division/type of hazardous materials anticipated to be most generally transported - (Check all that apply.)
❏Div 1.1 Explosives (with mass explosion hazard)
❏Div 1.2 Explosives (with projection hazard)
❏Div 1.3 Explosives (with predominantly fire hazard)
❏Div 1.4 Explosives (with no significant blast hazard)
❏Div 1.5 Very insensitive explosives; blasting agents
❏Div 1.6 Extremely insensitive detonating substances
❏Div 2.1 Flammable gas
❏Div 2.1 LPG (Liquefied Petroleum Gas)
❏Div 2.1 Methane Gas
❏Div 2.2 Non-flammable compressed gas
❏Div 2.2 A (Anhydrous Ammonia)
❏Div 2.3 A (Poison Gas which is Poison inhalation Hazard (PIH) Zone A)
❏Div 2.3 B (Poison Gas which is PIH Zone B)
❏Div 2.3 C (Poison Gas which is PIH Zone C)
❏Div 2.3 D (Poison Gas which is PIH Zone D)
❏Class 3 Flammable and combustible liquid
❏Class 3 A (Flammable liquid which is a PIH Zone A)
❏Class 3 B (Flammable liquid which is a PIH Zone B)
❏Combustible Liquid (Refer to 49 CFR 173.120 (b)
❏Div 4.1 Flammable solid
❏Div 4.2 Spontaneously combustible material
❏ Div 5.1 Oxidizer
❏ Div 5.2 Organic peroxide
❏ Div 6.1 A (Poison Liquid which is a PIH Zone A)
❏ Div 6.1 B (Poison Liquid which is a PIH Zone B)
❏ Div 6.1 Poison (Poisonous liquid with no inhalation hazard)
❏ Div 6.1 Solid (meets the definition of a poisonous solid)
❏ Div 6.2 Infectious substance (Etiologic agent)
❏ Class 7 Radioactive material
❏ HRCQ (Highway Route Controlled Quantity of Radioactive material)
❏ Class 8 Corrosive material
❏ Class 8 A (Corrosive liquid which is a PIH Zone A)
❏ Class 8 B (Corrosive liquid which is a PIH Zone B)
❏ Class 9 Miscellaneous hazardous material
❏ Elevated Temperature Material (Meets definition in 49 CFR171.8 for an elevated temperature material)
❏ Infectious Waste (Meets definition in 49CFR 171.8 for an infectious waste
❏ Marine Pollutants (Meets definition in 49 CFR 171.8 for a marine pollutant)
❏ Hazardous Sub (RQ) (Meets definition in 49 CFR 171.8 of a reportable quantity of a hazardous substance)
❏ Hazardous Waste (Meets definition in 49 CFR 171.8 of a hazardous waste)
❏ ORM (Meets definition in 49 CFR 171.8 of Other Regulated material)
Note: Information on Poison Inhalation Hazards is found in column (7) of the hazardous materials table (49 CFR 172.101)
INTRA / INTER HAZARDOUS MATERIALS CARRIERS/SHIPPERS – IS YOUR COMPANY REGISTERED WITH RSPA?
Please refer to 49 CFR, Part 107.601 regarding the applicability of registration of persons who offer or transport hazardous materials. If your company meets the criteria listed, call Research and Special Programs Administration (RSPA) of the Federal Highway Administration at (202) 366-4109 for the appropriate application forms or download from http://www.rspa.dot.gov .PART 4 EQUIPMENT LISTING / TERMINAL & DOCK FACILITIES
List the following information for all vehicles (power units) and equipment (trailers) to be operated under the license. Attach additional pages if necessary. A computer printout listing the power units/equipment/trailers information required may be submitted.
POWER UNITS
Vehicle I.D. Number (VIN)
Year
Make
Type*
Describe Type
GVWR or Capacity
Tag No
State
Owned(O) or Leased(L)
* Type of power unit such as Straight Truck (ST), Truck Tractor (TT), Pickup (PU), Limousine, Taxi, Car, etc. If “Other”, please describe in the column called “Describe Type.”
EQUIPMENT / TRAILERS
* Type of Equipment or Trailers such as Gooseneck, Flatbed, Box, Belly Dump, Pole Trailer, etc.
DESCRIPTION OF TERMINAL or DOCK If your company does not maintain a terminal, dock or motor pool facility, please list the physical address (physical location) where vehicles are parked when not in use. _______________________________________________________________________________________________________
_______________________________________________________________________________________________________
PART 5 SAFETY SUMMARY REPORT
1. Does applicant intend to operate vehicles with a GVWR or GCWR over 26,000 pounds? ❏YES or ❏NO
2. Does applicant intend to transport hazardous materials requiring placarding? ❏YES or ❏NO
3. Does applicant intend to transport hazardous waste requiring a uniform manifest? ❏YES or ❏NO
4. Are your company’s CDL drivers employees and/or owner/operators?
❏Employees ❏Owner/Operators ❏Do not have CDL drivers
5. Provide applicant's USDOT safety rating:
❏No safety rating ❏Unsatisfactory ❏Conditional ❏Satisfactory ❏ Do not know
APPLICANT CERTIFICATION - SAFETY
The applicant certifies the federal motor carrier safety regulations, as adopted by the State of Oklahoma, will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for.
Initials
APPLICANT CERTIFICATION - SIZE AND WEIGHT SUMMARY REPORT
The applicant certifies the size and weight law as set forth by the State of Oklahoma, will be observed and complied with fully in the exercise of any and all rights acquired through the permission to operate as hereby applied for.
Initials
Vehicle I.D. Number (VIN)
Year
Make
Type*
GVWR or Capacity
Tag No
State
Owned(O) or Leased(L)